Fitting Child Flashcards
How common is it to have a seizure?
- 8% of children have one seizure by 15 years of age
- Most seizure stop by 2-3 minutes, from onset
- Longer the seizure last, the less likely it is to stop
- A child that presents to you fitting is likely in status epilepticus
Definition of status epilepticus?
- Prolonged seizure activity lasting greater than 30 minutes
- Recurrent seizures without the regain of consciousness lasting greater than 30 minutes
When do you start management for a seizure?
- 5 minutes as by then, it is likely to continual longer than this
When might a seizure cause long term sequelae?
30 minutes or longer
What is the mortality rate of status epilepticus?
- In past, mortality rates in children have ranged from 6-18%
- First year of life: 17.8%
- 0-6 months: 24%
- 6-12 months: 9%
What are the longterm complications of status epilepticus?
- Neurological sequelae of Convulsive SE
- Epilepsy,
- motor deficits,
- learning difficulties, and
- behaviour problems are age dependent
- occurring in 6% of >3 years
- but in 29 percent of those
What are the causes of status epilepticus?
- Prolonged Febrile Seizure – is the most common cause of Status Epilepticus ( 32 % )
- Febrile: sole provocation is fever
- Acute symptomatic (insults to the brain)
- CNS Insult: meningitis, encephalitis,
- Metabolic disturbance – hypoglycaemia
- Incracranial lesion – tumour/ head trauma,
- Remote Symptomatic :
- Past insult with resultant seizure disorder
- Remote Symptomatic with an acute precipitant –
- underlying seizure d/o but something ppt –
- just because underlying seizure disorder doesn’t always explain the status – e.g electrolyte disturbances
- Precipitants of SE: missed medications, sleep deprivation, fever & infections, medications that lower the seizure threshold
- Still Need to look for acute causes
How do you approach assessment of a seizure?
- BLS- DRSABCD
- Dangers- PPE – risk of COVID-19
- Sending for help
- Time the seizure
- ABCDE
- Maintain Airway- Provide oxygenation
- Monitor Breathing & Vital Signs
- Circulation- obtain IVaccess, BP
- Disability- responsiveness
- Exposure- rash / bruising as a sign of injury /measure temperature
- Fluids
- Glucose - DEFG : Dextrose: check glucose levels
- Electrolytes: check electrolytes (Na, Ca, Mg, PO4), and anticonvulsant levels
- History
- Description, warning, what was the child doing before the spell,
- Focal or tonic clonic
- Length of seizure
- Multiple clusters of seizure activity
- Examination
- Investigations
- Always do a blood glucose level (BGL), Calcium, Magnesium, other electrolytes Na,
- Venous blood gas
- Consider other investigations according to the possible underlying aetiology e.g. infectious screen anti-epileptic drug levels, toxic screen
What advice do you do for generalised ronic clonic seizures out of the hospital setting?
- DO
- Stay with person and protect from injury (especially the head)
- Time seizure
- Roll person on their side
- Monitor breathing
- Reassure person until recovered
- DON’T
- Put anything in person’s mouth
- Restrain the person
- Move person unless in danger
What do you do if a seizure last >5 minutes?
- Benzodiazepine Therapy
- Midazolam
- Dosage 0.15 mg/kg IV
- OR 0.3 mg/kg Buccal
- ( max 10 mg )
- 100 kg 15 years – 10 mg is still max
Describe the advanced paediatrics life support for seizures?
What do you do if a seizure goes on for 10 minutes?
- Intubate
- Another dose of Midazolam
- 2nd line- Phenytoin preferred
- Needs an urgent Venous blood gas to decide next step
- 2nd Line- Levetiracetam
Another dose of Midazolam
When do you give a second line anticonvulsant in a prolonged seizure?
- 1 minute
- 2-3 minutes
- 5 minutes
- 10 minutes
- 15 minutes
- 30 minutes
15 minutes
If two doses of benzodiazepines do not work for seizure management, what side effect do you consider and what should you consider to be the cause?
- Important side effect of BZD to consider
- Respiratory depression
- BZD internalization
- BZD ( receptors) GABAA (gamma‐aminobutyric acid) receptors move from the synaptic membrane to the cytoplasm, where they are functionally inactive.
What options are available for second line treatment in seizure management?
- Phenytoin
- 20 mg/kg iv load
- Can be diluted in 0.9% sodium chloride only
- Phenytoin must not be mixed with glucose solutions
- Max infusion rate of 1mg/kg/min, over 20 mins
- Stops seizures in 10-30 minutes
- Duration of action 24 hrs, T 1⁄2=24hr
- IV Levetiracetam (Keppra )
- 40 mg/kg rapidly infused ( 20-40 mg/kg)
- Can be loaded more rapidly over 5-10 minutes
- 2-4mg/kg/min (vs Phenytoin 1mg/kg /min)
- ( does not need serum levels )
- Phenobarbital (especially in infants)
- Lipid solubility < phenytoin
- Duration of action>48 hrs, T1/2= 100 hours
- Dose 20 mg/kg
- Side Effects: sedation, decreased respiration and BP
Describe the algorithm for seizure management after second midazolam dose has been given
Describe the seizure management algorithm after the first choice of second line drug is given
